Physiotherapy in burns

Physiotherapy in burns

1. Physiotherapy
in Burns
By- Dr. K. K. Patel (MPT)
Assistant professor

2. What Is Burns…?
It is a type of coagulative necrosis of tissue.caused by thermal application
transfer from source to body.

3. Types of burn
Ordinary burns-
Scald-
Electric burn –
Chemical burn-
Radiation burn –
Cold burn-
Frost bite-

4. Aetiology of Burns
Ordinary burns- it is caused by dry heat with fire, open flame, hot metal or
aero plane crash in civil life and bomb injury in war.
Scalds are caused by moist heat

5. Electric burn are caused by an exogenous electric shock. Common causes of
electrical burns include workplace injuries or being defibrillated or
cardioverted without a conductive gel
Chemical burns are usually caused by caustic chemical compounds, such as
sodium hydroxide , silver nitrate, and more serious compounds (such as
sulphuric acid and Nitric acid)
.

6. Radiation burns are caused by protracted exposure to UV light (as from the
sun), radiation therapy (as patients who are undergoing cancer therapy),
sunlamps, and X-rays. By far the most common burn associated with
radiation is sun exposure,

7. Inhalation burns:-
Direct thermal injury can be sustained by inhalation of flames, hot gases or
steam.
This places a major threat to the upper airway,
causing oedema of the larynx, pharynx and
trachea.

8. EPIDEMIOLOGY
SKIN :
ANATOMY
THE EPIDERMIS
STRATUM GERMINATIVUM
STRATUM SPINOSUM
STRATUM GRANULOSUM
STRATUM LUCIDUM
STRATUM CORNEUM
THE DERMIS
THE SUBCUTANEOUS TISSUE

10. FUNCTIONS :
Maintains body fluid
and electrolyte balance
Regulate body temp
Protect body from invasion
Sensation
Physical appearance

11. CLASSIFICATION OF BURNS
Superficial Burn (Epidermal Burn)
It Causes damage only to the epidermis
The classic sun burn is the best example
The skin remains intact, the erythema lasts for a
few days, and the patient does not normally
seek medical help unless the problem is
extensive.

12. Heal within 2-3 days and no scar will be present

13. Superficial partial thickness burn
Damage occur through the epidermis and into the papillary layer of the dermis
The epidermal layer is destroyed completely but dermal layer sustains only mild
to moderate damage.
The most common sign of is the presence of intact blister over the affected area
Heal within 7- 10 days with minimum scaring

15. Deep partial thickness
It involves destruction of the epidermis with damage of the dermis down
into the reticular layer. Most of the nerve ending, hair follicle and sweat
glands will be injured because most of the dermis is destroyed
Deep partial thickness burn has a mixed red or waxy white color. The
deeper the injury it appear more white

16. If infection does not occur it heal within 3-4 weeks
The development of hypertrophic and keloid scar are a frequent
consequence of DPTB

17. Full thickness burn
In this all of the epidermis and dermal layer are destroyed completely.
In addition subcutaneous fat layer may be damaged to some extend
A full thickness burn is characterized by hard parchment like ESCHAR
covering area.
Skin grafting is necessary

19. Sub-dermal burn
An additional category of burn,
It involves complete destruction of all tissue from epidermis down to and
thro the subcutaneous tissue, muscle and bone may be damaged
This type of burn occurs with prolonged contact with flame and hot liquid
and routinely occur as a result of contact with electricity

21. Alternate classification

23. Burn wound zone
Burn wound consists three zone
1.Zone of coagulation
2.Zone of hyperaemia
3.Zone of stasis

25. The Zone of coagulation cells are irreversibly damaged and skin
death occur.
This area equivalent to a FTB and will require a skin graft to heal
because lake of visible tissue and amount of eschar, the risk of infection
is increased

26. The zone of stasis
Containing injured cells that may die within 24- 48 hours without diligent
treatment.
It is the zone of stasis that infection, drying, and/or inadequate perfusion of
the wound resulting conversion of potentially salvageable tissue to
completely necrotic tissue and enlargement of zone of coagulation

27. The Zone of hyperemia
Is the site of minimal cell damage, and the tissue should recover within
several days within no lasting effect.

28. Extend of burn area
To calculate rapidly an estimate of the percentage of TBSA burned Polaski and
Tennison developed rule of nine
This rule divides the body surface into area that are 9 percentage or multiples of
9, of the total body surface.
Lund and Browder modified the percentages of body surface area to account
for continuum of age and to accommodate for growth of the different body
segment

29. This method is the more accurate means of the two method to determine
the extend of burn injury

30. Head front 4.5
Head back 4.5
Upper trunk front 9
Upper trunk back 9
Lower trunk front 9
Lower trunk back 9
Upper limb front 4.5 Lt +4.5Rt = 9
Upper limb back 4.5 Lt +4.5 Lt =9
Lower limb front 9 Lt +9 Rt =18
Lower limb back 9 Lt+ 9 Rt = 18
Perineum 1
Total = 100

34. PROGNOSIS OF THE BURNS PATIENT
Age :- Burns in people aged over 60 years or under 5 years carry a poor
prognosis.
Total burn surface area (TBSA):- The greater the total burn surface area,
the poorer the prognosis.
A formula for outcome is:
Percentage chance of survival = [100 - (age in years + percentage TBSA)].

35. For example, a 60-year-old with 30% TBSA has a 10% chance of survival
[100 - (60 + 30)]. A method for gauging the total body surface area is 'the
rule of nines'.

36. Complication of burn injury
It is depend on the extend of burn, the depth and type of burn, there may
be secondary systemic complications.
In addition, the health, age, and psychological status of the patient who is
burned will be affect these complications.

37. Infection-
In conjunction with organ systemic failure,
Pseudomonas aeruginosa and staphylococcus aureus.
Pulmonary complications
Patient who burned in closed space should be suspected of having an
inhalation injury.

38. Incidence of pulmonary complication is extremely high after the sever burns,
and that death due to pneumonia alone is attributed to a majority of the
deaths following burn injury
Sign of inhalation injury included facial burn, singed nasal hairs, harsh cough,
hoarseness, abnormal breath sound, respiratory distress and carbonaceous
sputum and/or hypoxemia

39. Primary complications associated with this injury are carbon monoxide
poisoning, tracheal damage, upper airway obstruction, pulmonary oedema,
and pneumonia
Metabolic complications
Most recent advances in burn treatment and rehabilitation have come
directly from the increase understanding of the metabolic demand of burn
injury and from the ability to improve the patient’s nutritional status to
meet these demands,

40. The consequence of increased metabolic and catabolic activity following a
burn are rapid decrease in body weight, negative nitrogen balance, and a
decrease in energy stores that are vital to the healing process.
As result of increased metabolic activity there will be an increase of 1° to 2 °c
in core temperature that seems to be due to a resetting of the
hypothalamic temperature centre in brain.

41. There is a significant relationship between the increase evaporative heat loss
from the impaired skin barrier over a burn and the hyper metabolic state.
If an individual with burns are kept in a room with normal ambient
temperature, excessive heat loss will be exhibited, and this will further
exaggerate the stress response seen in these patients. Therefore it is
recommended that room temperature be kept at 30 °,which will
significantly reduced the metabolic rate

42. Cardiovascular complications
There may be tremendous initial decrease in cardiac output.
There is alterations in platelet concentration and function, clotting factors and
WBC components; RBC dysfunction and decrease in hemoglobin and
hemocrite

43. Heterotropic ossification
Patient with burns are highly susceptible to the development of HO.
Suspected etiologies include greater than 20% TBSA burn.
immobilisation, micro trauma, high protein intake, and sepsis.
Neuropathy
Peripheral neuropathy in patients with burns can take two forms:
Polyneuropathy or local neuropathy

44. Pathological scar
Burns scars occur in areas of deep partial thickness bur that are allowed to
heal spontaneously and in full thickness burns that have been skin grafted,
but where graft coverage is incomplete, scar become pathological when they
take on the form of hypertrophy, contracture or both.

45. Management of burns
First Aid
Flame burns must be smothered.
Cold water applied continuously over the burnt
area relieves pain and limits the depth of the
burn, because heat is conducted to the deeper
tissues for several minutes after the flames
have been extinguished.

46. With chemical burns, contaminated clothing must
be removed and copious quantities of running
water applied to the area. Neutralizing agents
need to be identified and applied accordingly.
With scalds, thorough and continuous dousing
with cold water can limit the extent of the
damage and reduce the pain.
With electrical burns, the patient may require
CPR before attention can be paid to the injury

47. Hospital Referral
Minor burns
These are defined as less than 10% surface
area in a child or less than 15% in an adult.
If the injury is noncomplex these injuries are
cleaned with chlorhexidine and covered with
a bactericidal non-stick dressing.
The dressings are changed every 2-3 day

48. Major burns
These are injuries that involve 10% or more
of the body surface area in children and
15% or more in an adult.
If the injury is complex the patient will be
admitted to the burns unit or intensive care
unit.

49. Early hospital management
(including the shock phase).
This involves:
Maintenance of a clear airway
Pain relief
Assessment of TBSA
Maintenance of fluid balance
Removal of adherent clothing and covering of
the burns with sterile cotton dressings

50. Application of neutralizing agents for chemical
burns
Reassurance and explanation to the patient
Transfer to a burns unit or admission to an
intensive care unit.

51. Fluid replacement is administered over a 36-hour period (from the
occurrence of the burn, not the time of arrival at hospital).
The volume of plasma required by the burns patient is related to the TBSA
and the size of the patient.
To calculate the volume of fluid required for resuscitation, the following
formula is used:
ml of plasma = TBSA X age of patient

52. The wound areas
Open method:-
This method leaves the wound exposed.
If exudate is cleaned away regularly, the area
dries out.
Bacterial growth is inhibited and this method
is used for areas that are difficult to dress,
such as the face.

53. Closed method
The primary layer of dressing is non-adherent,
for example petroleum jelly gauze.
This is then covered with layers of absorbent
cotton gauze , held in place by crepe bandages
or net.
With bandages securing the dressings the patient
may be able to begin to mobilise about the ward
with the aid of the physiotherapist

54. Surgical Management of Full-Thickness
Burns
Escharectomy is removal of the dead, burnt skin by a method of
excision or shaving.

55. Grafting involves covering the open tissues with a layer of split skin.
This may be from an uninjured area on the patient (an autograft) or
from another person (allograft).

57. Skin Substitutes :- Consists of cultured autologous skin, which is grown in
laboratory. It is taken from biopsy of patient’s own tissue, use of altered
cadaver skin and other biologically engineered tissues
Surgical correction of scar contracture :- Z- Plasty

58. REHABILITIVE PHYSIOTHERAPY
The aims of Physiotherapy are to:
•Achieve a clear airway and so prevent respiratory
complications
•Maintain joint range of movement, and prevent
contractures or deformities
•Maintain soft-tissue length
•Maintain muscle strength

59. •Regain maximum function
•Minimise scarring
•Help the patient to gain independence and
return to an active lifestyle.

60. Respiratory Care
Shaking, clapping, postural drainage, coughing and
suction can be used to clear secretions.
Tipping is contraindicated if there is facial oedema but
the patient may lie supine or on either side.
A ventilated patient usually requires suction and
humidification.

61. •Breathing (expansion) exercises are also important to
maintain ventilation of all lung areas.

62. +
Intensive respiratory care is required in the following
situations:
For the elderly patient
For burns affecting face, mouth and respiratory passages
For immobile patients
Where there is a history of a chronic respiratory
condition
Pre and postoperatively for patients with a full-thickness
burn to the chest to keep the eschar mobile.

63. Joint Range of Movement
Positioning, splinting and exercise are used for
maintaining and improving joint range.
Positioning: The position of comfort for the patient is
usually that of joint flexion.
Unfortunately this allows scar tissue to contract and cause
deformities

64. Positioning is given to –
Decrease edema
Maintain soft tissue in elongated state

65. •The correct positions to be maintained are described
below.:-
Head and neck
A small roll (towel) behind the neck and/or a pillow under
the shoulders will help to maintain extension of the
cervical spine.
The patient may be in lying (chest and leg burns) or in
half-lying with facial burns (because of facial oedema).

66. Upper limbs
The upper limbs should be elevated on pillows with the
shoulder in abduction and slight flexion, the elbows
and wrists in extension, and the hands with
metacarpophalangeal joints in flexion, interphalangeal
joints in extension, and thumb in palmer abduction.
The joints of the hand are held in position by static
splints.

67. Lower limbs
The lower limbs are rested with the hip joints in
extension and slight abduction, knees in extension and
ankles in 90-degree dorsiflexion (in a foot drop splint).
Elevation is obtained by raising the end of the bed, not by
placing pillows under the legs, which would put the
hips into flexion.

68. Splinting –
Given in antideformity positions.
Indications
•To prevent contractures
•Maintenance of range of motion achieved during
exercise session or surgical release.
•Correction of contracture
•Protection of joint or tendon.

71. •Splints should be simple so it is easy to apply, remove
and clean.
•They are usually worn at night, when patient is resting
or continuously for several days following grafting.
•It should confirm to body part and there should not be
any pressure points.
•They should be routinely checked for proper fit and
revised if necessary.
•Splints may be static or dynamic.

72. Static splints
Static splints are used when it is essential to
maintain a certain joint position until movement
can start or to maintain a satisfactory resting
position between exercises.
These are designed and made to individual
requirements using thermoplastics and modified
as the patient recovers, such as after passive
stretching.
Splinting may be required at night only to prevent
soft tissue tightening.

73. Dynamic splints
Dynamic splints can permit controlled
movement of various joints.
Dynamic Finger MCP joint flexion and thumb
abduction splint

74. Flexor Grove
Rigid Collar for burns
over neck and chest

75. General points for Splinting
The position has to be effective, but not necessarily the
position of function.
Joints must not be included unnecessarily in splints.
Tight encircling must be avoided.
Grafts and flaps must not be subjected to pressure from
the splint material.

76. Bony prominences must be avoided where possible or
require corresponding padding within the splint.
Nerve compression must be avoided.
Correction and prevention of deformity is essential but so
too is muscular activity. Therefore, intermittent and
dynamic splinting must be used where possible.

78. Exercises
Active exercise .
Assisted active exercises or passive movements are
necessary for the damaged limbs and free active exercise
for undamaged areas.
If the patient is sedated and unable to perform exercises,
passive movements must be carried out at regular
intervals.
Movement should be performed frequently to reduce
oedema and resultant joint stiffness.

79. If skin graft, active and passive range of motion exercises
are discontinued for 3 to 5 days to allow graft to adhere.
After that, begin gentle active exercises and then passive if
needed.
To keep healed burned area moist, it should be lubricated
before exercises are initiated.
Care should be taken around areas of skin grafts and stress
should be applied in a gentle, prolonged and gradual
fashion.
If burn wounds are well healed,Modalities such as
ultrasound may be used to increase pliability of tissues
before exercises.

80. Exercise can be very painful; where possible treatment
should be time tabled to coincide with the patient's
medication .
The physiotherapist may perform passive movements
through the dressings or the hand bags.
If movement is restricted by the adherence of the
dressings, then treatment can be carried out when the
dressings are down.

81. Once the patient is alert enough and the intravenous drips
and lines are minimal, the patient can sit out and attempt
standing.
A tilt table may be used to gradually bring the patient into
the vertical position. Once the patient is able to stand,
walking is commenced.
As soon as possible the patient must be encouraged to be
independent in self-care and activities of daily living.

82. Muscle strengthening
Muscles working over joints, which are fixed, can be
worked isometrically.
The use of small weights, graded rubber exercise bands
and springs can increase muscle strength.

Therapist should monitor vital signs while doing
exercises.

83. Aerobic exercises
Ambulation is initiated at the earliest appropriate time.
Assistive devices can be used.

84. SCAR MANAGEMENT
Following wound closure, a skin graft or healed burn
wound is vascular, flat and soft. The newly healed areas
may become raised and firm.
Pressure is used to minimize hypertrophic scar formation
by thinning dermis, altering biochemical structure of
scar tissue, decrease blood flow to area, reorganizing
collagen bundles, decreasing tissue water content.

85. Earlier scar tissue is exposed to pressure, better the
result.
If wound heals in less than 10-14 days such as in
superficial partial thickness burns -------- pressure may
not be indicated.
If wound heals in longer than 10-14 days such as in deep
partial thickness burns ------- pressure is indicated.

86. Pressure Dressing :-
Elastic wraps are used to control edema and
scarring.
Garments are measured when a patient has only a
few remaining open areas.
Garments are very tight and difficult to apply but
pressure is necessary to prevent scar
hypertrophy.

87. Garments can be ordered for any or all body
parts.
Garments can be worn when skin or scars can
tolerate shearing force of application.

90. Massage :-
Deep Friction Massage

91. Outpatient Physiotherapy
The Physiotherapist should assess the range of movement,
the healing process and scar formation.
Contractures must be prevented by regular passive
stretching, and mobility of scar tissue is maintained by
techniques of scar management.

92. When all the wounds have fully healed and the grafts are
stable, the patient is assessed and measured for pressure
garments.
Return to Active Lifestyle

93. Follow Up Care
Home exercise program :-
Range of motion exercises
Massage
Encourage patient to perform ADLs
Patient’s family member / caregivers should be
able to apply and remove all splints and pressure
appliance independently
Proper skin care : Soap with no perfume should
be used. Moisturizing soap used after all open
areas are healed

94. Moisturizing creams should be applied 2-3
times a day and should not contain perfumes
or have significant alcohol content.
Patient should avoid sun exposure.
Itching may be present so cream should be
applied.